Charter Boat Application

Charter Boat Application – Vessel 25

Complete this application to provide all required charter, vessel, crew, and insurance information for Vessel 25.
Applicant & Policy Information
Applicant Name*
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Proposed Policy Period (Start Date)*

MonthDayYear
Date
Proposed Policy Period (End Date)*

MonthDayYear
Date
Business Phone
Email Address

Mooring Location:

General Information
Operations:
YesNo
If Yes, provide details
Current Insurance Carrier
Current Insurance Premium
Does the account use the vessel personally? Please describe:
Name of current pleasure craft carrier (if used for personal use) and effective date:
Hull

Deductible Requested ($1,000 Minimum)*
Personal effects and fishing equipment*
Mortgage information
Navigation limits
Warranted lay-up period (include how vessel will be laid up)
Protection and Indemnity
Limit request $1,000,000
BI Deductible:
PD Deductible:
Charters
Describe typical charter in detail -- be specific on type of charter and average length of trip
Number of years in charter business?*
Maximum passengers?*
Average passengers?*
YesNo
YesNo
Number of charter days per year?
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, please indicate.
Date of Last Survey

MonthDayYear
Date
Please Attach

Cancelof
Crew
YesNo
YesNo
YesNo
YesNo

Crew Experience:

Maximum crew working on applicant's vessel at any one time?
Total number of crew employed by applicant?
Provide details of pre-employment program carried out prior to hiring any new crew (physicals, drug/alcohol screening, back x-rays or MRI's, reference checks, etc.)
When was the pre-employment put in effect?

MonthDayYear
Date
If vessel(s) operate in hurricane zones, please describe wind plan or attach written wind plan:
File Upload

Cancelof
Loss Experience

List all claims (insured or not)during past 5 years of all operations. (ATTACH FULL LOSS EXPERIENCE DETAILS)

File Upload

Cancelof
Applicant Signature*
Date Signed (Applicant)*

MonthDayYear
Date
Agent or Broker Name
Broker Signature
Date Signed (Broker)

MonthDayYear
Date
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
Should be Empty:

Charter Boat Application – Vessel 25